Welcome to this person centred support plan, which is something you might like

to try with one or two people living in your care home. The plan emphasises the

need to take account of the perspective of the person with dementia and it should

be completed in the first person, i.e. from their point of view. This might feel

strange to begin with but it helps to create an ethos, which responds to the

wishes and needs of people with dementia. The guiding principle of the plan is

that it should be enabling and support the person with dementia to be as self-

reliant and in control as they can be.

The format of this plan has been shared with the Care Quality Commission and if

used correctly and kept up-to-date it should not cause problems on inspections.

The format was developed in response to concerns by inspectors that care plans

were not person centred and often failed to highlight risks arising from people’s

physical and mental conditions.

The plan has two parts:

1. "My support plan - at a glance” - a top sheet which provides a

snapshot for quick reference. It aims to help people to see the person with

dementia as an individual. It offers potential areas for discussion and

engagement and highlights critical needs. It can be copied separately and

may be particularly useful for agency staff, ancillary staff (e.g. housekeepers)

and visiting agencies (e.g. ambulance staff, GPs and nurses). It can also be

Person centred support plan for people with dementia

South West Dementia Partnership

Living well with dementia across the South Westwww.southwestdementiapartnership.org.uk

provided to hospital staff, dentists and others who may provide care or

treatment to the person with dementia away from the care home.

2. "My support plan - in detail” - this draws upon the theories of Tom

Kitwood. According to Kitwood, the experience of living with dementia is the

result of a person’s neurological impairment, their physical health, their

biography, their personality and the “social psychology” surrounding them.

“Social psychology” refers to the relationships, environment and activities

which provide opportunities for the person with dementia to be engaged with

others and meaningfully occupied. Kitwood proposed that improving “social

psychology” provides the greatest opportunity to enhance the experience of

people living with dementia. This support plan is designed to achieve this.

Completing this type of support plan may take 3 to 4 weeks initially, while staff

get to know the person and seek information in order to build up a picture. Over

time more and more will be learnt about the person and can be added to the

plan, and revisions made in response to changing needs. Clearly as much

information should be obtained directly from the person, either through

discussion or close observation. It is useful to do as much early on as possible,

for opportunities will be lost as the dementia progresses.

Completing the plan is more about making the effort to get to know the person

being cared for as it is about completing the paperwork. It is best done by a key

worker can also become the champion for that particular individual. It should be

seen as an intriguing piece of detective work rather than administrative chore!

The support plan should be kept simple. Clearly other documents will need to

exist alongside it including basic information with essential contact details and

specific detailed care planning documents where these are necessary e.g.

pressure area care, end of life care plan etc.

This can be cross-referenced in the support plan.

Some homes also prepare a more detailed life history book, which are

invaluable.

SafetyThis section is essentially a risk assessment which flags up any areas of serious

concern at the start of the support plan. It should highlight significant, real risks

pertinent to the person not speculative or generalised risks. There may be “no

risks identified” for the person concerned above those you would generally have

about people living in your home.

The section “what you must do to keep me safe” is an opportunity to record

action being taken to promote the person’s best interest as defined by the Mental

Capacity Act, e.g. DoLS.

Cognitive abilityAlthough there are some commonly recognised effects, the experience of

dementia varies widely between individuals depending on the type of dementia,

the part of the brain affected and the stage of dementia.

A memory assessment, if one has been done, should provide helpful clues about

the abilities which remain intact, and processes which the person has difficulty

with and the support required. Typically problems will centre on visual

processing, body management, memory, auditory processing, language,

planning, judging and controlling. Dementia can also cause confusion,

hallucinations and mis-identification.

The components that define mental capacity under the Act should be considered

in the four sections.

Neurological impairment is a complex area however Chapter 7 of Enriched Care

Planning for People with Dementia provides an excellent, clear explanation of

dementia and the brain. It describes the effects of different types of dementia and

the support, which can be offered.

BiographyThere are many examples of how life story work has had a very positive benefit

for people with dementia. People's backgrounds are very important to understand

particularly if people are unhappy or become distressed. Particular activities in

the care home, or the approach by a member of staff may trigger powerful

feelings related to painful events in someone's past.

There may also be repetitive behaviours and mannerisms, which are hard to

fathom.

There are often clues in people’s life histories, which can help to provide

explanations and possible solutions.

Conversely there are also clues in people's life histories about activities that

people might enjoy and the skills they might retain. This will inform staff about

what they can do to make life in the care home meaningful and relevant.

“And Still the Music Plays” provides a number of accounts which illustrate just

how important biography can be in supporting people with dementia.

PersonalityPersonality is basically the way people approach the world; their natural

disposition. Some people are confident, outgoing and positive. They enjoy trying

new things and can adapt easily. Others tend to be more reserved and inward-

looking. They might be more anxious about change and being amongst

unfamiliar people.

Some people like to be organised, and efficient whilst others are more laissez-

faire and more relaxed about life. People can also vary in the extent to which

they are emotional or like having physical contact with others.

When a person is faced with living with dementia the way they respond will

depend on their personality. Some will battle on, perhaps experiencing a lot of

frustration as a consequence, others will become depressed when nothing

seems to be going right and as a result become increasingly withdrawn and

depressed.

Recognising that individuals have different personalities helps staff to respond in

a way which is in tune with the person’s personality. For example, a retired navy

officer who likes to feel organised might feel more reassured if they are dressed

smartly and have everything in order around him. He may be averse to physical

contact and feel more comfortable with a formal approach from staff.

Chapter 4 of Enriched Care Planning for People with Dementia offers a template

to assist with profiling personality.

Physical healthThis section will include the individual health needs, which most homes are used

to identifying and planning for. It should also address washing and bathing.

Clearly providing health support to people with dementia can have added

complications. Pain management is a particular concern as it may be hard for the

person with dementia to recognise that they are in pain or give expression to this.

Providing physical interventions to someone with dementia, e.g. injections, may

also pose challenges as the person with dementia may not recognise the need

for support or react negatively to being given assistance.

Continence and dementia raises some interesting issues. Toilet training happens

early in life and the associated skills and learning are unlikely to be lost at early

stages of dementia. Problems however often arise because of perceptual

processing and negotiating the environment, i.e. a person who appears to be

incontinent may not be. It is that they have difficulty in completing the tasks

associated with getting to the toilet.

Every effort should be made to promote self-toiletting by identifying and removing

barriers and improving access to toilets. This should be given careful

consideration under the environment section of the plan.

Eating and drinking have been included under physical health because nutrition

and hydration are essential to physical well-being. It is an area of study in its own

right and an area in which it is easy to make mistakes because people with

dementia may not pick up on cues.

However eating and drinking are also strongly related to other sections of the

support plan particularly relationships and occupation.

EnvironmentCareful observation of a person living in a care home can reveal a lot about the

way the environment supports them and promotes access around the home and

the extent to which it creates barriers. Sitting in the wrong location can be

distressing because of the stimuli in that area or because access to important

facilities is difficult.

Supporting mobility and manual handling has been included under environment

to stress the importance of promoting access.

CommentsThe plan can be downloaded, printed and completed in paper-based format. It

can also be downloaded as a word document and completed electronically. This

means it can be changed over time.

The plan looks long but in fact is fairly easy to write and absorb. The use of a

marker pen can enable priority needs to be highlighted.

We would welcome feedback on use of the plan. If you have any comments

please email them to david.francis@dh.gsi.gov.uk.

For more information on work across the South West region to improve care in

care homes visit the South West Dementia Partnership website

www.southwestdementiapartnership.org.uk/implementation/care-homes/

Good luck!

,

My name:

I like to be known as:

My birthday:

Important people to me:

Insert picture here

My background, skills and interests: I like:

I dislike:

Tips for talking to me:

My critical care and support needs:

My support plan - at a glance

What you need to knowS

afet

y

Areas of high risk for me:

What you must do to keep me safe:

My support plan – in detail

My name:

I like to be known as:

What you need to know

Cog

nitiv

e ab

ility

How dementia has affected my thinking and doing:

What I can still do:

What I find difficult:

How you can help me to do the things I can still do and support me with the things I find

difficult:

What you need to know

Bio

grap

hy

What is important for you to know about my past:

How my past affects the way I am today:

How you can support me to make the best use of my past and overcome any difficulties

it causes for me:

What it is important for you to know about my cultural background:

How you can support me to maintain my cultural identity:

What you need to know about my use of language:

What you need to know

Per

sona

lity

How I am generally as a person, my disposition:

How I respond to new situations and difficulties.:

What upsets me:

How you can support me to be positive and help me when I am distressed or

withdrawn:

What you need to know

Phy

sica

l hea

lth

What I can still do for myself:

What I find difficult:

How you can help me with my physical health:

What you need to know

Phy

sica

l hea

lth: e

atin

g an

d dr

inki

ng

Things I enjoy:

Things I do not like:

This is how and where I prefer to eat:

These are things I must have:

How you can help me with eating and drinking:

What you need to know

Sen

sory

Impa

irmen

t

My good senses are:

What I find difficult:

How you can help me to make best use of my senses:

Spi

ritua

lity

These are my beliefs, which are really important to me:

How you can help me to sustain them:

What you need to know

Occ

upat

ion

This is what I like to be doing:

This is how you can help me to do it:

Ent

erta

inm

ent

This is what I enjoy:

Things I do not enjoy:

What you need to know

Env

ironm

ent

The environment which best suits me is one where:

These are the challenges I have:

This is how you can support me to make the best of the world around me:

What you need to know

Fam

ily, f

riend

s an

d co

mm

unity

People and organisations which are important to me:

How you can support me with maintaining these relationships:

How you can support them to maintain a relationship with me:

What you need to know

Oth

er p

eopl

e

How I like to be around others and how I like others to be around me:

How you can support me with maintaining relationships:

Document history

Completed by: Date:

Last revised by: Date:

With information from (please tick)

Person ❒ Relative ❒ Agencies ❒ Other ❒ Observation ❒

Agreed with:

Signature of person Signature of relatives